Improving Community Health with Informatics and Patient-engagement (ichip)

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Bernadette Armstrong
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1 Improving Community Health with Informatics and Patient-engagement (ichip) A Two Year Project to Improve Patient Portal Adoption, Cancer Screening, and Blood Pressure Control using Quality Navigation and Self-monitoring William G. Adams, MD and Charles T. Williams, MD Boston HealthNet

2 Moving Toward Population Health: Improving Cancer Screening and Blood Pressure Control Pilot project (6 months, Summer 2014, 3 sites) tested use of quality navigators and DRVS within the BHN Recognized potential for improving patient engagement via EHR portals and the value of systematic registry use (DRVS) In Spring of 2015, BHN Medical Directors asked to identify high priority goals for a full proposal that could leverage MyCHART and navigators Directors selected cancer screening and prevention and control of hypertension selected Project funded in Fall 2015 (Partnership for Community Health) Winter 2015 Centers: Codman Square, DotHouse, Greater Rosindale, Mattapan, South Boston, South End, Uphams Corner

3 Overview Importance of targeted conditions Goals, approaches and strategies Results Lessons learned and next steps

4 Hypertension Facts 29% of adults have hypertension 45% unaware (NHANES III) Hypertension increases your risk of death, particularly from stroke, MI and CKD

5 Risk/Benefits of treating HTN over 5 years NNT Death 1 in 125 Stroke 1 in 67 MI 1 in 100 NNH Side effect or stopped 1 in 10

6 Boston HC for the Homeless Codman Square Dorchester House East Boston Greater Roslindale Mattapan South Boston South End Upham's Corner BMC - FM BMC - GIM BMC - Peds At goal Network Data by Site 2014 Hypertension Controlling High Blood Pressure (NQF 0018) Percent Upper Control Limit Lower Control Limit Group ave Goal 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Site

7 Percent of primary care patients with essential HTN whose latest systolic BP was < 140 and diastolic BP was < 90 by census tract. Patients were assigned to a tract if they had at least one address listed in the tract during

8 Cancer Facts Colorectal cancer (CRC) second leading cause of cancer death amoung men and women combined. 1 in 20 persons will be diagnosed with CRC. Cervical cancer - 13,240 new cases will be diagnosed this year. Screening (PAP) has been responsible for major decreases in cases and deaths. Breast cancer most common cancer and second leading cause of cancer deaths amoung women. 1 in 8 women will be diagnosed with breast cancer. 39% reduction in deaths between

9 Performance Data March 2015 Measure South Boston Dorchester House Codman Square Uphams Corner Mattapan Gr Roslindale South End Colorectal CA 39% 54% 46% 61% 35% 57% 42% Cervical CA 54% 60% 60% 50% 40% 74% 51% Breast CA 73% 69% 62% 70% 51% 67% 33%

10 Project Goals Leverage two HIT systems within 7 CHCs in Boston advanced data analytics via a cloud-based quality measurement and patient population management system (DRVS, Azara Healthcare); and a centrally-supported patient-portal (MyCHART, OCHIN Epic EHR) to promote self-care by patients Measurably improve MyChart adoption, cancer screening (CRC, breast, and cervical) and blood pressure control by January 2018 Achieve MyChart activation rates of >= 20% Improve Cancer Screening by 10% Improve Blood Pressure Control by 5%

11 1) Wildly Important Goals (WIGs) 2) Lead Measures 3) Compelling Scorecard 4) Cadence of Accountability

12 Teams and Resources Boston HealthNet: Bill Adams, Charlie Williams, Ramon Cancino/Kathryn Levasseur, Eva Zaret, Judi Henderson and two health promotion specialists 7 BHN CHCs each with a quality lead and 50% of a navigator In-kind support from OCHIN MyChart Team

13 ichip Logic Model

14 Phase 1 MyChart Promotion/Training 60 days after go live began active recruitment/support Developed Change Package with tools, measures, and support materials Targeted MyChart enrollment initially Identified pilot clinicians and users for home BP monitoring Cancer screening data migration optimization Transfer as much data as possible Create workflows for continuous improvement Optimize Reporting DRVS, Acuere, Clarity, Workbench

15 MyChart Enrollment

19 Blood Pressure Control

20 Mattapan CHC Steady improvement 58.7% to 70.4%

21 HTN Intervention Checklist The Mattapan Protocol by Ramon Cancino Patient Outreach 1. Use DRVS registry to identify patients with a diagnosis of HTN whose last blood pressure reading was abnormal and have not been seen in the last 2 months a. Schedule RN visit for blood pressure check b. Inform the patient to bring all medications to visit c. Consider provider visit if has not been seen in >6 months During Nurse Visit 2. Blood Pressure check a. If elevated recheck in 10 minutes measuring manually by RN b. Guidelines/Goals see next page 3. Medication reconciliation a. Are you taking medications? Which medications? How are you taking them? Any barriers to adherence? 4. Education - sign/handouts/avs a. Normal blood pressure/goals b. DASH diet c. Other: 5. MyChart a. Quality Navigator Teaching, flow sheet, home blood pressure check if available 6. If BP recheck abnormal/not at goal a. Schedule provider visit same day or next day for medication changes and further education 7. Develop plan with patient on reducing blood pressure 8. Follow-up appointment scheduled 2-4 weeks for RN visit a. OR home blood pressure monitoring and follow up by phone or MyChart

22 HTN Best Practices 1. Run registry of uncontrolled BP patients, outreach to those not seen in last 2 months and schedule a visit 2. MA taught to check BP 3. MA checks BP if elevated waits 10 min and rechecks 4. At visit use APHTN smart phrase to set goal and make a change. 5. Schedule a FU in 4 weeks if uncontrolled

23 Navigator Run the registry NQF 0018 in DRVS (Azara) visit in last 12 months Example => Mattapan Dx HTN (at all sites this is likely an under count) Uncontrolled (>139/89) at last visit Moderate to severe (>159/99) last visit > 2 month ago. Call these patients 1st

What is a Healthy Blood Pressure? O que é uma Pressão Arterial Saúdavel? Qué es una presión sanguínea saludable? Ki sa ki yon tansyon an sante? Một khỏe mạnh huyết áp là gì?

24 What is a Healthy Blood Pressure? O que é uma Pressão Arterial Saúdavel? Qué es una presión sanguínea saludable? Ki sa ki yon tansyon an sante? Một khỏe mạnh huyết áp là gì? Blood Pressure For Patients Less Than 60 years old Pressão arterial para pacientes < 65 anos de idade. La presión arterial para pacientes < 65 años de edad Tansyon pou pasyan < pi piti pase 65 an Huyết áp cho bệnh nhân < 65 tuổi 140/90 Blood Pressure For Patients older than 60 years old Pressão arterial para pacientes > 65 anos de idade La presión arterial para pacientes > 65 años de edad Tansyon pou pasyan > gen 65 an a pi gran Huyết áp cho bệnh nhân > 65 tuổi 150/90

28 Cancer Screening

29 80% 70% Colorectal Cancer Screening Rates 69% 60% 50% 49% 49% 50% 47% 48% 40% 30% 33% 35% 38% 20% 10% 0% DotHouse Massachusetts National

30 Cancer Screening Best Practices 1. Optimize data quality 2. Work with hospital to improve access 3. Standardize use of alternatives to colonoscopy 4. Use DRVS to identify gaps in care 5. Reach out to patients

31 Phase 2 Monthly team calls review dashboard and share best practices Weekly ichip leadership calls Site visits by medical director and ichip team (April 2017) Integration into existing clinical and executive meetings Health promotion specialists on-site MyChart recruitment -> outreach and data management

32 Results

33 Visit-based MyChart Enrollment by Site 45% 40% 35% 30% 25% 20% 15% 10% 5% 0%

34 40.00% % of MyCHART users by MA CHC (12 month lookback) 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% ichip CHC ichip CHC OCHIN - All ichip CHC OCHIN - All Other - A Other - B ichip A ichip B ichip C Other C ichip D Other D ichip E ichip F ichip G Non-iCHIP 5.00% Source: OCHIN, April % Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18

35 MyChart Useage ichip 2017 Center Cancel Appt Make Appt Health Maintenance Medical Advice Refills Total

36 Final Survey Results* Strongly Agree Agree Disagree Strongly Disagree NA-DK 1. I can answer Patient Questions about the benefits of MyChart 35% 40% I am able to sign-up Patients for MyChart when they ask me 25% Patients can use MyChart to request appointments Patients can use MyChart to request medicatio refills Patients can use MyChart to request Medical Advice *7 CHCs and 326 Respondents

37 100.0% HTN Control ichip 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

38 4/1/2016 5/1/2016 6/1/2016 7/1/2016 8/1/2016 9/1/ /1/ /1/ /1/2016 1/1/2017 2/1/2017 3/1/2017 4/1/2017 5/1/2017 6/1/2017 7/1/2017 8/1/2017 9/1/ /1/ /1/ /1/2017 1/1/2018 2/1/2018 Axis Title 75.0% HTN Control by Site 70.0% 65.0% 60.0% 55.0% 50.0% 45.0% 40.0%

39 UCL LCL 48% 50% 52% 54% 56% 58% 60% 62% 64% 66% 1/31/15 2/28/15 3/31/15 4/30/15 5/31/15 6/30/15 7/31/15 8/31/15 9/30/15 10/31/15 11/30/15 12/31/15 1/31/16 2/29/16 3/31/16 4/30/16 5/31/16 6/30/16 7/31/16 8/31/16 9/30/16 10/31/16 11/30/16 12/31/16 1/31/17 2/28/17 3/31/17 4/30/17 5/31/17 6/30/17 7/31/17 8/31/17 9/30/17 10/31/17 11/30/17 12/31/17 1/31/18 2/28/18 3/31/18 4/30/18 NFQ 0018 (controlling BP) BHN ichip P Chart Percent

40 100.0% Cervical Cancer Screening Rates - ichip 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

41 80% Cervical Cancer Screening Rates by Site 75% 70% 65% 60% 55% 50% 45% 40% 35% 30%

42 2/29/16 3/31/16 4/30/16 5/31/16 6/30/16 7/31/16 8/31/16 9/30/16 10/31/16 11/30/16 12/31/16 1/31/17 2/28/17 3/31/17 4/30/17 5/31/17 6/30/17 7/31/17 8/31/17 9/30/17 10/31/17 11/30/17 12/31/17 1/31/18 2/28/18 3/31/18 4/30/18 Percent 80% Screening Cervical Cancer (NQF 0032) BHN ichip - UDS monthly P Chart 75% 70% 65% UCL LCL 60% 55% 50% 45% 40%

43 100.0% Colon Cancer Screening Rate - ichip 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%

44 100% Colon Cancer Screening Rates by Site 90% 80% 70% 60% 50% 40% 30% 20%

45 1/31/15 2/28/15 3/31/15 4/30/15 5/31/15 6/30/15 7/31/15 8/31/15 9/30/15 10/31/15 11/30/15 12/31/15 1/31/16 2/29/16 3/31/16 4/30/16 5/31/16 6/30/16 7/31/16 8/31/16 9/30/16 10/31/16 11/30/16 12/31/16 1/31/17 2/28/17 3/31/17 4/30/17 5/31/17 6/30/17 7/31/17 8/31/17 9/30/17 10/31/17 11/30/17 12/31/17 1/31/18 2/28/18 3/31/18 4/30/18 Percent 62% CRC Screening (NQF 0034) BHN ichip April phase p chart 60% UCL 58% 56% LCL 54% 52% 50% 48%

46 Breast Cancer Screening Rate - ichip 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0%

47 100.0% Breast Cancer Screening Rates by Site 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0%

48 QN and Quality Director Feedback 1) MyChart helps providers build stronger relationships with patients in-between clinic visits 2) Patients are more involved in their health 3) Patients are able to better manage their BP 4) Patients don t wait or call to view labs or request rx refills 5) Parents get their child s immunization and important forms/letters they need for school 6) Increased awareness of quality measures among staff generally

49 Lessons Learned 1. On-site leadership is critical 2. Improvement team visits increase engagement 3. ALL CHC staff should be encouraged to participate 4. Targeting multiple measures adds complexity 5. Home BP monitoring was harder than we thought 6. MyChart enrollment should be an expectation not an option 7. Extending teams with Quality Navigators works 8. Changing EHRs adds complexity 9. Network based improvement adds value

50 Planning for the Future 1. Now have the foundation for an improvement network 2. Ongoing support of QN s likely give ichip success and ACO priorities 3. 4DX approach promising for future work 4. Optimal use of EHR, portals, and reporting solutions will continue to be critical

51 Questions for Audience 1. How are you approaching portal enrollment? 2. Does your center have a role like our QN? 3. Do you have easy access to compelling scorecard? 4. How are you approaching reminder/recall functionality for uncontrolled HTN and cancer screening?

52 If another CHC were to replicate your project, what advice would you share with them? 1) Consider a patient portal (MyChart) as an essential and integral part of health care delivering. 2) Engage key leadership from the very beginning. 3) Build a network. Our project leveraged web-enabled communication, regular meetings, and on-site support from our clinical leaders and project support staff. In isolation, each CHC would have achieved less but though this collaboration achieved more. 4) Be realistic about the ability of patients to obtain and use BP cuffs at home. We thought this would be much easier than it was. While some patients used the technology very well (100+ entries), for many more the barriers to use were too high. 5) Find a compelling way to share data regularly. 6) Develop clear and consistent guides and materials to support consistent improvement work. 7) Engage the entire CHC team so that everyone having contact with patients is included in the effort to get patients enrolled into MyChart. 8) Consider using a train the trainer approach to QN early on to share best practices quickly

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